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Oa Waste Tire Survey & Inspection Report iinspection Report Number <br /> CalRecycle State of California 11 1245182 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Fora, m Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details - <br /> TPID- <br /> Inspection Type(Fill one) <br /> Site Suffix: 01 <br /> 5 5 l� q 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0.y-\ ��p� V�� CQv� 0 CHP 0 CalRecycle o Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ! v\ <br /> AeT T' <br /> Inspection Date <br /> l K Time In Time Out <br /> Business Rep Title AM <br /> Q AM 7 <br /> r- 2 C) 6 ` <br /> 0PM • z 46 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive 40 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXE <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days a <br /> 0 0 <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 19 In Compliance-No Violations o <br /> 0 1 0 Other:§ <br /> Comments ` V_p W Ol <br /> Inspection Form Included: 0 <br /> Comments Included: cid <br /> (� Za G, 1—l6G7737��-�� ` <br /> Business Rep's Signature Phone Number Inspe tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:9 Incorrect: IEIXIAIMIPLE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />